LASIK: Basic steps for great results

Transcription

1 LASIK: Basic steps for great results ESCRS 2009 A. John Kanellopoulos, M.D. Associate Professor of Ophthalmology l NYU Medical School, NY Director: Laservision.gr Eye Institute, Athens, Greece

2 My Background Harvard dmdi Medical lsh School Cornea lc Fellow Fll Cornell University Cornea Fellow Medical Director TLC Laser Eye Centers Director: Refractive Surgery, NYU Director, Laservision.gr Institute Associate Professor: oesso NYU Medical School Over LASIK procedures

3 Experience Excimer Excimer Lasers Summit Apex plus VISX S2, S3 and S4 Wavescan Lasersight Nidek Alcon Ladarvision B&L: Technolas 217 Wavelight: 200Hz Wavelight eye Q 400Hz VISX custom View Wavelight Blue line

4 LASIK Has been around for almost 20 years About 1.5 million eyes in the US per year One of the safest procedures in Medicine Permanent vision correction

5 The procedure About 10 minutes Eye is anesthetized with drops Minimal discomfort Rest for the rest of the day Medications for 1 week

6

7

8

9

10

11 One of the initial LASIK cases, 1994

12

13 LASIK Advantages Minimal discomfort Rapid visual recovery Both eyes can be done Stable correction

14 Possible complications Glare/Halos Over/under correction Astigmatism Flap wrinkles Haze Infection

15 Other Options Intacs Phakic IOLs Bioptics (LASIK and Phakic IOL) Clear lens extraction

16 Patient Selection Not quite easy No cookbook approach A Physiologic and Anatomic factors B Emotional and Psychological Characteristics

17 First INFO? Referred patient Why does the pt want surgery Has the pt had previous consultations

18 History Very Important FHx Keratoconus? Or PK Medical Dx and Meds CL history very crucial (RGP vs SCL) Presbyopia, any bifocals or previous experience with monovision

19 Topography pachymetrypachymetry

20 X 95

21 Edge detection via software

22 4 maps refractive Application: Enhanced overview for refractive surgeons in values and maps Hand out to patients

23 Topometric Application: Enhanced overview for refractive and cataract t surgeons Detailed corneal structure analysis Q < 1=prolate Q > 1=oblate Q = 0 = sphere

24 Concept of Reference Sphere To see relevant features, global curvature mustbe removed The topographic maps of TERRESTRIAL LANDSCAPES are displayed in the form of constant elevation Reference contours, surface measured (sphere) from the mean sea level of the earth For the CORNEA, a reference surface (typically, a sphere) is constructed by fitting the reference surface as smooth as possible to the data surface (Best Fit Sphere) e) In corneal topography the reference surface is not some fixed mean sea-level, but is movable

25 anterior (+) Color Scale: Elevation Map reference Max Red high anterior to the reference surface (-) posterior Min Blue low posterior to the reference surface Relative elevation measures height difference in microns from a best- fitting reference sphere In all elevation maps, green is the reference surface or zero level Red is high and positive, Blue is low and negative

26 Screening patients

27 Screening patients

28 Pupil size

29 Case # 9 ORB Scan Pentacam, post LASIK, Ectasia? Yes with ORB Scan Not with Pentacam

30 Case # 11 ORB Scan Pentacam, post LASIK, Ectasia? Yes with ORB Scan Not with Pentacam

31 Case # 11 ORB Scan Pentacam, post LASIK, Ectasia? Yes with ORB Scan Not with Pentacam

32 Selected cases

33 Contact Lens related scar and vascularization BSCVA: 20/100

34 Pentacam driven PRK and CCL 0.1% riboflavin + 7mW/cm2 X 15minutes

35 before Post topo-guided PRK and CCL

36 Patient 2 75y/o male s/p PRK in the Pseudophakic OS has now significant haze, irregular hyperopic astigmatism UCVA 20/200 BSCVA 20/50 with @ Significant superficial and anterior stromal haze exists He is referred dfor a cornea graft 36 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 36

37 Pre operative Topography: Topolyzer 37 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 37

38 Pre operative Topography: Oculyzer 38 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 38

39 Topography Ablation Profile 39 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 39

40 OcuLink Ablation Profile 40 40

41 Wavefront Optimized TM Ablation Profile 41 41

42 Pre operative Wavefront Map Non available K haze 42 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 42

43 43 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 43

44 Wavefront Ablation Profile Non available 44 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 44

45 Treatment: 50 microns PTK at 7mm OZ Topolyzer guided treatment (due to the haze a nd irregularity was anticipated to be more accurate than the Oculyzer guided Tx UVA CCL 3 mw/cm % riboflavin 30 minutes 45 A. John Kannellopoulos, M.D., PhD, WaveLight Global Ambassador, Athens, Greece & New York, USA 45

46 At 3 m UCVA 20/40, : 20/

47 Enlarging myopic optical zone: Initially -10, 505µ LASIK: 4,5mmOZ, 125µ flap M2->plano ^BCVA 2 lines, but night halostopo-guided Tx to enlarge OZ to6mm and adjusting Q value to -1,46Initially halos gone, Refraction: -1.25!

48 Post-trauma irregular astigmatism Old K perf, s/p CE, IOL,s/p LASIK for now -1, irregularbcva 20/40+ Topoguided, Qadjustment to -0.3 Postop: UCVA 20/30, BCVA 20/25

49 Post-surgery irregular astigmatism Complicated CE-Aphakia-Artisan IOL-in an old LASIK pt Complicated CE Aphakia Artisan IOL in an old LASIK pt P BCVA 20/60 Postop UCVA 20/25

50 Re-centering OZ, smoothing irregularities (Loss of K sliver in recuts)

51 Centering optical zone-hyperopia Initially: , post LASIK: UCVA: 20/40 BCVA 20/25 ptopog: plano UCVA 20/20

52 Enlarging optical zone-rk 10 year post-rk, Post- LASIK: +2,50-1,50Cyl, debilitating night vision. P topo-guided marked improvement

53 Enlarging optical zone-hyperopia S/p LASIK for +4.50, now and night vision down C3, s/p topo-guided d CS=C7

54 Post-keratitis irregular astigmatism Patient with old severe Cornea ulcer and paracentral flattening irregular cyl UCVA 20/200 to 20/25 BSCVA from 20/40- to 20/25

55 Good LASIK candidate?

56

57

58 OCT

59 Post LASIK

60 Summarize with Pt What are their expectations? Va CC and SC What is their TOPO, Pach, Pupil, IOP, RE, Hd Hydration state, Seasonal state

61 Presbyopia In the over 40 Pts discuss CL and spec correction for near In the under 40 Pt, demonstrate reading with cyclo (best effect if CL users) Remember: not all pts understand presbyopia How does your pt spend his/her typical day?

62 Monovision demo Be different, show your pt that you care prior to suggesting g LASIK CL or specs trial of mono (remember myope presbyopes see better at near with specs and hyperopes with CLs

63 Personality Warning signs Pts request warranty RGPcls LISTEN to your staff! What exactly have they read on the web? Again what is their daily activities?

64 Excessive CL use! Clinical signs of CL over use Theyneed an exception 10 days off scls $ weeks off RGP CL use per decade of use Myopic shift in sphere and cyl seen following cessation of CLs (especially RGPs)

65 Problem Pts: Impatient/Hostile Ptsthat that repeat findings not discussed Most Pts will still hear selective info The 50 y/o who wants to be 25 The Pt with 3 pages of typed questions

66 The problem Pt Asks not only your surgical experience but type of equipment and has opinion of his own Pt is unhappy with previous procedure Pt is shopping h for a competitive ii price The divorcee

67 The problem Pt: Engineers: expect textbook tissue response Teachers: Always very demanding Pts with multiple problems desperate for a good outcome The confused patient

68 Physiologic Contraindications Systemic: RA/ Collagen Vascular Disease IDDM Immunomodulated pts

69 AMD Physiologic Contraindications Eyelid diseases Ocular: Functional Monoculars POAG with ON damage, most cataracts, small orbits, high buckles,? Previous Vit RE outside your range

70 Physiologic Contraindications Ocular: Bizarre keratometric and refractive data? Poor pupil dilators and wide pupils Very dry eyes, severe eyelid imbrication and lagophthalmos h l (may require smaller MK cut)

71 Physiologic Contraindications Neurotrophic Keratitis Fuchs dystrophy Corneal: Very flat (myopes) Very steep (hyperopes) Scars in Vaxis Hx of HSV keratitis Previous refractive surgery? KCN, other K ectasias

72 Measurements Topography (regularity, keratometry) Pachymetry Pupil size Refraction? Wavefront Complete eye exam

73 Key specifications that are important for the clinician: the frequency of the flying spot treatment is 400 Hz the spot size is 0.9 mm; its active eye tracking system involves an infrared camera and three individual illumination modules to sense the eye movement (by fixing on the pupillary reflex) with a detection frequency of 250 Hz and areaction time 6 to 8 msec

74 Key Features

75 Experience Microkeratomes B&L: ACS, Hansatome Alcon:SKBM Allergan: Amadeus Moria: LSK, M2, epik Intralase 30 and ow 60FS Wavelight: Rondo, Ultra flap

76

77 Methods: We evaluate amount of myopia and astigmatism, pre and post operative: UCVAand BSCVA, IOP, endothelial cell count IOL Master, autor, and wavefront, Pentacam. We utilized the Intralase 60FS, previously the M2. Informed consent

78 My Technique

79 Placement of the M2

80 Microkeratome pass

81 Folding of flap, even moisture on stromal bed

82 Check parameters Intraoperative moistute eq

83 Irrigation of flap and careful wipe

84 milky drop to delineate gutter

85 2 observation interval

86 My technique 1 Drop of Alcaine Betadine drape Isolate eyelids with drape Aspirating speculum Lubricate blade and rotating parts with Alcaine!!!

87 My technique Careful check of lock Alcaine during MKassembly on eye Technician observes tubing Avoid pt sqeeze

88 My technique Taco flap to minimize Dehydration Even bed hydration very important

89 My technique Irrigation very important Squeeze out excees fluid and Striae with moist Weck cell Milky steroid can help delineate gutter and flap striae

90

91 7D myopia corrected in same pt One eye (top) with the Allegretto Wave The other eye (bottom) with the Technolas 217c Larger ablation with the Allegretto is a result of better approach to prolate cornea

92 Comparison of topography guided (TGL) to standard LASIK (SL) for hyperopia. How important is adjustment for angle kappa? ESCRS 07 A. John Kanellopoulos, MD Associate Professsor, NYU, New York Laservision.gr, g, Athens, Greece

93 Hyperopia-standard p treatment Kanellopoulos-JRS 2006 Initial topography guided Hyperopic and Hyperopic pi Astigmatism tism LASIK Experience with the WaveLight ALLEGRETTO WAVE excimer laser in 120 Consecutive Eyes ARVO 2006-JRS 2006

94 Is Angle kappa significant in hyperopes? 2007 J Refract Surg in Measurement of angle kappa with synoptophore and Orbscan II in a normal population p Hikmet Basmak, MD 1 ; Afsun Sahin, MD 2 ; Nilgun Yildirim, MD 3 ; Thanos D. Papakostas, MD 4,5 ; and A. John Kanellopoulos, MD 4,5 There isa significantcorrelation correlation between positive refractive errors and large positive angle kappa values. Refractive surgeons must take into account angle kappa especially in hyperopic patients in order to avoid complications related to decent ration of ablation zone.

95 Angle kappa adjustment topo link These figures depict tthe same planned excimer profile for the correction of hyperopic astigmatism on the left: centered on the pupillary center and on the right :adjusted by topography to take into consideration and adjust for angle kappa

96 LASIK flap needs to be de centered as well to accommodate Challenging for surgeon, Intralase?

97 Treatment axis is centered on the visual axis and not pupil center

98

99 Conclusions TGL and SL appear to be safe and effective for hyperopia. TGL appears be superior in regard to regression, residual astigmatism, CS and EAD This platform achieves superior visual axis centration with a smaller re treatment rate compared to our previously published series. It reduces the chance of a surgeon related decentration error. Oculyzer link maybe faster and more accurate

100 Mthd Methods 1000 consecutive cases in our refractive surgery center in Athens, Greece are screened for the following elements: 1 Dry and dilated d (1% mydriacyl) di refraction, dry and 2 dilated auto refraction (Nikon speedy K), 3 pentacam topography (Wavelight oculyzer),

101 Methods (2) 4-wavefront analysis (Wavefront Tsernning analyzer), 5-pupilometry (Procyon), 6-contrast sensitivity ii i (Vector Vision) Vii 7-and a complete slit lamp biomicroscopy including dilated fundus exam.

102 Methods (3) For patients over 40 a trial with contact lenses is performed reflecting several monovision scenario to accomplish patient eye dominance and preference. The results were compared with a matched group of 1000 cases treated t previously with the M2 microkeratome and the same excimer laser

103 Treatment tform

104 video

105

106 1000 i LASIK cases Lasevision.gr Institute, Athens Started on October myopic, 220 hyperopic Retrospective comparison with 1000 consecutive M2 cases M2 flaps aim 100 to 110 microns myopia Large cut 130SU in hyperopia Femto: 110 microns for myopia, 130 hyperopia

107 Intralase FS 60 Vs M cases incomplete flaps 3 2-Completed 1-PRK 6- all PRK Flap striae-suturing 0 6 Epi ingrowth 0 22 flap myopia 105 +/ mm 100 +/ mm flap hyperopia 135 +/ mm 127 +/ mm buttonhole 1 3 Epi-abrasion (ABM dystr) 2 65 DLK Light HSS 0 (maybe 1 late post abrasion) 0 0 0

108 Posterior cornea surface change I LASIK and M2 LASIK

109 Prophylactic CCL

110 Flap suturing

111 Bowman s buttonhole

112 Epi ingrowthingrowth

113 Epi abrasion

114 Total free cap

115 Flap replace

116 Femto on old LASIK flap

117 Conclusions Thorough preoperative screening and disposable instrumentation in Femtosecond and excimer refractive surgery reduces the risks for DLK, and flap complications such as striae and epithelial ingrowth and results in safer, more effective visual rehabilitation ti

118 Our current protocol Myopes: 70% standard dprolate optimized treatment F CAT with the Eye Q Q, 400Hz, Q value adjustment RMSH>0.4 Wavefront guided High cylinder: topo guided Hyperopes: p 100% topo guided with q value adjustment Enhancements: 100% custom

119 Thank you